Agreement of Musculoskeletal Ultrasound and Clinical Assessment of Shoulder Impairment in Manual Wheelchair Users With Various Duration of Spinal Cord Injury

Models of care for musculoskeletal shoulder pain in spinal cord injury: A scoping review

CONTEXT

Spinal cord injury (SCI) is a neurological condition that significantly impacts a person's lifestyle, health and well-being. Many individuals with SCI experience secondary musculoskeletal shoulder pain. This scoping review examines the current research on the diagnosis and management of shoulder pain in SCI.

OBJECTIVE

The aim of this Scoping Review was (1) to chart peer-reviewed literature regarding the diagnosis and management of shoulder pain as it relates to SCI and (2) identify gaps in this body of literature to inform future research priorities.

METHODS

Six electronic databases were searched from inception until April 2022. In addition, reviewers scanned the reference lists of identified articles. Articles from peer-reviewed sources that reported diagnostic or management procedures for musculoskeletal shoulder conditions within the SCI population were considered and 1679 articles were identified. Title and abstract screening, full text review, and data extraction were undertaken by two independent reviewers.

RESULTS

Eighty seven articles were included, covering diagnosis or management of shoulder pain in SCI.

CONCLUSION

Whilst the most commonly reported diagnostic procedures and management strategies reflect contemporary practice for shoulder pain, the entire body of literature demonstrates inconsistencies in methodologies. In places, the literature continues to perceive value in procedures inconsistent with best practice. These findings encourage researchers to pursue the development of robust models of care for musculoskeletal shoulder pain in SCI using a collaborative and integrated approach, combining best practice for musculoskeletal shoulder pain alongside clinical expertise in the management of SCI.

Subacromial Content to Subacromial Space Ratio in Neutral Position of the Arm as Diagnostic Criteria of Subacromial Impingement Syndrome

Background

Shoulder impingement syndrome is one of the main causes of shoulder disability of working-class individuals. Currently, dynamic sonography of the shoulder is the modality of choice for the evaluation of shoulder impingement syndrome. The ratio of subacromial contents (SAC) and subacromial space (SAS) in neutral arm position could be used as a diagnostic parameter for the subacromial impingement syndrome (SIS), especially in patients who have difficulties in the elevation of their shoulders due to pain. To use the SAC to SAS ratio as a sonographic criterion for the diagnosis of SIS.

Methods

SAC and SAS of 772 shoulders were vertically measured in coronal view with linear transducer 7-14MHz of Toshiba Xario Prime ultrasound unit, while the patient arm was kept in the neutral position. The ratio of both the measurements was calculated, to be used as a diagnostic parameter of the SIS.

Results

The mean SAS was 10.79 ± 1.94 mm and SAC was 7.65 ± 1.43 mm. SAC-to-SAS ratio for normal shoulders was a focused value with narrow standard deviation (0.66 ± 0.03). However, shoulder impingement is confirmed by any value falls out of the range of ratio for normal shoulders. Area under the curve at 95% confidence interval was 96%, while the sensitivity at 95% confidence interval was 99.25% (97.83%-99.85%), and specificity was 80.86% (76.48%-84.74%).

Conclusion

SAC-to-SAS ratio in neutral arm position is a relatively more accurate sonographic technique for the diagnosis of SIS.

Biomechanical analysis of wheelchair athletes with paraplegia during cross-training exercises

CONTEXT

Extreme conditioning programs (ECPs), such as CrossFit^®, are a relatively new method of fitness with rapid growth in individuals with paraplegia. However, it is unknown if wheelchair users are at an additional risk of musculoskeletal injury during these exercises. Biomechanical characterization is necessary to determine the safety and efficacy of ECPs as an exercise modality for wheelchair users with paraplegia.

OBJECTIVE

To characterize the three-dimensional (3-D) thorax and upper extremity joint kinematics of paraplegic wheelchair athletes during exercises commonly prescribed as part of ECPs.

DESIGN

Observational study.

PARTICIPANTS

Three male wheelchair athletes, average age of 37.1 ± 4.6 years, with spinal cord injury levels of T8, L2, and T10, with varying exercise experience.

METHODS

3-D movement was acquired using motion capture during the performance of four exercises: battle ropes, sled pull, overhead press, and sledgehammer swing. A custom upper extremity inverse kinematics model was applied to compute 3-D joint angles.

OUTCOME MEASURES

3-D peak thorax, glenohumeral, elbow, and wrist joint angles and ranges of motion (ROM), Visual Analog Scale (VAS), and Borg Scale of Perceived Exertion.

RESULTS

Large joint motions were required for the exercises, at times demanding extreme shoulder and/or wrist flexion and extension, abduction, and external rotation, which are concerning for injury risk in wheelchair users. Participants, however, were able to perform the exercises pain free.

CONCLUSION

These quantitative findings highlight that wheelchair athletes may be exposed to potentially injurious positions during common ECP exercises. These findings provide insight that may lead to improved clinical guidelines for prescription and training of exercise regimens, particularly involving ECPs, for wheelchair users.

Shoulder magnetic resonance imaging findings in manual wheelchair users with spinal cord injury

Objective: To investigate the prevalence of rotator cuff and long head of the biceps pathologies in manual wheelchair (MWC) users with spinal cord injury (SCI).Design: Cross-sectional study.Setting: Outpatient clinic at a tertiary medical center.Participants: Forty-four adult MWC users with SCI (36 men and 8 women) with an average age (SD) of 42 (13) years. SCI levels ranged from C6 to L1; complete and incomplete SCI.Outcome Measures: Participants' demographic and anthropometric information, presence of shoulder pain, Wheelchair User's Pain Index (WUSPI) scores, and magnetic resonance imaging findings of shoulder pathologies including tendinopathy, tendon tears, and muscle atrophy.Results: Fifty-nine percent of the participants reported some shoulder pain. The prevalence of any tendinopathy across the rotator cuff and the long head of biceps tendon was 98%. The prevalence of tendinopathy in the supraspinatus was 86%, infraspinatus was 91%, subscapularis was 75%, and biceps was 57%. The majority of tendinopathies had mild or moderate severity. The prevalence of any tears was 68%. The prevalence of tendon tears in the supraspinatus was 48%, infraspinatus was 36%, subscapularis was 43%, and biceps was 12%. The majority of the tears were partial-thickness tears. Participants without tendon tears were significantly younger (P < 0.001) and had been wheelchair user for a significantly shorter time (P = 0.005) than those with tendon tears.Conclusion: Mild and moderate shoulder tendinopathy and partial-thickness tendon tears were highly prevalent in MWC users with SCI. Additionally, the findings of this study suggest that strategies for monitoring shoulder pathologies in this population should not be overly reliant on patient-reported pain, but perhaps more concerned with years of wheelchair use and age.

Shoulder Pain, Function, and Ultrasound-Determined Structure in Elite Wheelchair-Using Para Athletes: An Observational Study

PURPOSE

This study aimed to determine the relationship between shoulder pain, physical examination, and tissue pathology in manual wheelchair users competing in elite sport.

METHODS

Eighty elite para athletes who used a manual wheelchair for daily mobility were recruited from international track (n = 40), field (n = 19), and powerlifting (n = 21) competitions. Athletes were surveyed regarding shoulder pain history and symptoms (Wheelchair User's Shoulder Pain Index (WUSPI)), whereas independent blind observers measured signs (Physical Examination of the Shoulder Scale (PESS)) and tissue pathology (Ultrasound Shoulder Pathology Rating Scale (USPRS)). Relationships between measures for the total cohort and for subgroups defined by sporting discipline were calculated.

RESULTS

A large proportion of athletes reported a history of upper limb pain (39% dominant and 35% nondominant). For the total cohort, WUSPI score was 22.3 ± 26.9, PESS score was 7.4 ± 6.7, and USPRS score was 5.2 ± 4.0. There were no USPRS score differences between athlete subgroups; however, track athletes had lower WUSPI and PESS scores, especially compared with field athletes. The first principal component explained most of the variance in the WUSPI and PESS, which were strongly correlated (r = 0.71), and the second orthogonal component explained the USPRS, which did not correlate with either the PESS (r = 0.21) or WUSPI (r = 0.20). Subgroup analysis showed that track athletes had lower symptom scores for a given physical examination score.

CONCLUSIONS

Elite para athletes who use manual wheelchairs for daily mobility have a high prevalence of shoulder symptoms, positive signs on physical examination, and ultrasound-determined tissue pathology. Ultrasound-determined tissue pathology does not correlate with symptoms or signs. This information can help to guide clinicians in managing shoulder problems in this athlete population at high risk of injury.

Effect of Context-Dependent Modulation of Trunk Muscle Activity on Manual Wheelchair Propulsion

OBJECTIVE

The aims of the study were to reliably determine the two main phases of manual wheelchair propulsion via a simple wearable sensor and to evaluate the effects of modulated trunk and hip stimulation on manual wheelchair propulsion during the challenging tasks of ramp assent and level sprint.

DESIGN

An offline tool was created to identify common features between wrist acceleration signals for all subjects who corresponded to the transitions between the contact and recovery phases of manual wheelchair propulsion. For one individual, the acceleration rules and thresholds were implemented for real-time phase-change event detection and modulation of stimulation.

RESULTS

When pushing with phase-dependent modulated stimulation, there was a significant (P < 0.05) increase in the primary speed variable (5%-6%) and the subject rated pushing as "moderately or very easy." In the offline analysis, the average phase-change event detection success rate was 79% at the end of contact and 71% at the end of recovery across the group.

CONCLUSIONS

Signals from simple, wrist-mounted accelerometers can detect the phase transitions during manual wheelchair propulsion instead of elaborate and expensive, instrumented systems. Appropriately timing changes in muscle activation with the propulsion cycle can result in a significant increase in speed, and the system was consistently perceived to be significantly easier to use.

The Relationship between Clinical Tests, Ultrasound Findings and Selected Field-Based Wheelchair Skills Tests in a Cohort of Quadriplegic Wheelchair Rugby Athletes: A Pilot Study

Manual wheelchair use may determine shoulder joint overload and rotator cuff injury. Chronic shoulder pathologies can also influence the propulsion ability of wheelchair athletes with spinal cord injury (SCI) during sport activities. However, the relationship between shoulder pathology and wheelchair performances has never been explored. Therefore, the study aimed to investigate the correlation between shoulder pathologic findings with clinical tests and ultrasonography evaluation and the results of wheelchair performance tests. Nineteen quadriplegic wheelchair rugby players were evaluated to investigate the association between clinical and ultrasound shoulder pathologic findings and their correlation with the performance of field-based selected wheelchair skills tests (WSTs). The outcome measures were the International Wheelchair Rugby Classification Score, dominant and non-dominant Physical Examination Shoulder Score, and dominant and non-dominant Ultrasound Shoulder Pathology Rating Scale (USPRS). The WST was measured at the beginning and at one-year follow-up. A statistically significant correlation was found between the time since SCI and dominant USPRS (p < 0.005). The non-dominant USPRS was strongly related to WST at the beginning (p < 0.005) and the end of the study (p < 0.05). Data suggest that the severity of the non-dominant shoulder pathology detected on the ultrasound is related to lower performance on the WST. Chronic manual wheelchair use could be responsible for dominant SCI shoulder joint and rotator cuff muscle damage, while non-dominant USPRS could be related to performance on the WST.

Shoulder impairment and pain of individuals with newly acquired spinal cord injury compared to uninjured peers

STUDY DESIGN

Cohort study.

OBJECTIVES

Shoulder pain prevalence is high in those with spinal cord injury (SCI) and is associated with decreased function, participation restrictions and decreased quality of life. Limited evidence exists regarding physical impairments of newly acquired SCI. The current study compared musculoskeletal factors at rehabilitation initiation in individuals with newly acquired SCI to uninjured individuals. We hypothesized no impairment differences of shoulder pain, strength, mobility, muscle extensibility, or rotator cuff integrity would exist between groups.

SETTING

Multi-site laboratory setting.

METHODS

Thirty-five individuals with newly acquired SCI and age and gender-matched controls without SCI (n = 34) participated. Musculoskeletal Pain Survey, shoulder range of motion (ROM), strength, pectoralis minor muscle extensibility (PM) and tissue integrity [Ultrasound Pathology Rating Scale (USPRS)] were obtained.

RESULTS

Higher pain was reported by individuals experiencing new SCI along with lower strength across all bilateral measures, reduced elevation, external rotation, and horizontal adduction ROM, with large effect sizes. PM bilateral extensibility was reduced compared to controls, with moderate between group effect size; however, no USPRS score difference existed.

CONCLUSIONS

This study provided the first comprehensive clinical description for individuals with newly acquired SCI. In comparison to matched uninjured controls, participants with new SCI reported greater shoulder pain with impairments in mobility, strength, and extensibility. The identified early clinical impairments aligned with progressive impairment including further pain development and persistence. Awareness and modification of these early clinical impairments may lead to improved long-term outcomes, improving the overall health and well-being of individuals with newly acquired SCI.

SPONSORSHIP

Spinal Cord Injury Research Program Investigator-Initiated Research Award under Award No. W81XWH-17-1-0476.

Association of musculoskeletal pain, fear-avoidance factors, and quality of life in active manual wheelchair users with SCI: A pilot study

Objective: Limited evidence examines the association of psychological factors, such as fear of movement and pain catastrophizing, with musculoskeletal pain patterns in active manual wheelchair users with spinal cord injury (SCI). This study investigated the relationship among musculoskeletal pain, fear avoidance factors, quality of life (QoL), activity and duration of injury in individuals with SCI. Design: Cross-sectional correlational. Setting: Community setting. Participants: Twenty-six individuals with SCI (age = 42 ± 14 years, duration manual wheelchair use = 17 ± 13 years, work/school/volunteer hours/week = 31 ± 14; recreation/sports hours/week 10 ± 12). Outcome Measures: Demographics and self-report measures including the Musculoskeletal Pain Survey (MPS), Wheelchair Users Shoulder Pain Index (WUSPI), Tampa Scale of Kinesiophobia (TSK-11), Pain Catastrophizing Scale (PCS), Fear of Pain (FPQ), Subjective Quality of Life Questionnaire (SQoL), and the Social Interaction Inventory (SII). Spearman's rho (ρ) assessed correlation among measures. Results: Strong association existed between age and duration of injury (ρ = 0.66, P < 0.001). SQoL offered a strong, direct correlation with age (ρ = 0.63, P = 0.01), duration of injury (ρ = 0.70, P = 0.001), and strong, inverse relationship with MPStotal (ρ = -0.66, P = 0.003) and MPS shoulder subscore (ρ = -0.64, P = 0.004). WUSPI demonstrated strong, inverse association with self-reported work hours (ρ = -0.52, P = 0.02) and a strong, direct relationship to PCS (ρ = 0.79, P = <0001). PCS demonstrated a strong, inverse relationship to work/school/volunteer hours (ρ = 0.71, P < 0.001) and strong association to TSK-11_total (ρ = 0.61, P = 0.001). A moderate, inverse relationship was identified for recreational/sports hours and FPQ (ρ = 0.48, P = 0.03). Conclusion: This cyclical relationship of musculoskeletal pain, reduced activity, and maladaptive psychological factors allude to interdependence of factors, supporting the multidisciplinary approach to care.